Grandparents Information (for Nachas reports):

We would love to send updates about your child to their grandparents throughout the year.

Paternal

Full Name:

First NameLast Name

Address:

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number:

Area CodePhone Number

E-mail:

Maternal

Full Name:

First NameLast Name

Address:

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number:

Area CodePhone Number

E-mail:

Emergency Information

Emergency Contact Name #1

First NameLast Name

Relationship to child:

Home Address:

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Home Phone Number:

Area CodePhone Number

Work/Cell/Pager Number:

Area CodePhone Number

Physicians Name:

First NameLast Name

Physicians Phone Number:

Area CodePhone Number

Medical Insurance Company:

Group #:

ID #:

*

As the parent(s) or legal guardian of , I/we authorize any adult acting on behalf of Chabad of the Rivertowns Hebrew School to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment.

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.